Proper Documentation in Behavioral HealthCE
Produced by: Ed4Online
Although it receives less focus than service provision and the professional-client relationship, proper documentation and essential part of successful outcomes in behavioral health. Documentation has been identified as a fundamental and critical skill needed to communicate patient needs and responses to treatment. Documentation also allows behavioral health professionals the opportunity to detail their impressions and thought processes on client needs which is necessary to justify the interventions taken in treatment plans as well as any adjustments to the treatment plan (Garbarino, 2006). Documentation is recognized as being important in recording the progression of cases. In many instances, documentation is the sole chronicle of a clients' treatment across time. This is particularly important when counselors or other human service professionals leave an agency, as well as when clients leave treatment. In both circumstances, documentation remains to inform new human service professionals about the client’s attempt at treatment and engagement in services. For these reasons, documentation has been described as an important case conceptualization tool for human service professionals to learn how to conceptualize a case which ultimately results in more effective treatment. While the importance of proper documentation is often known at the administrative or executive levels, there are many challenges to regularly documenting treatment and interactions with clients among behavioral health professionals. Proper documentation requires skill, training, and time which is often difficult to obtain from behavioral health professionals due to the high workloads and challenging nature of their jobs More agencies and organizations should conduct training on proper documentation to inform behavioral health professionals on the importance of documentation and how to write case notes. Ensuring proper documentation ultimately improves service delivery.

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Proper Documentation in Behavioral Health